Indian J Anaesth. 2017 Feb; 61(2): 103–109.

doi: 10.4103/0019-5049.199855
PMCID: PMC5330066

Anaesthesia for adenotonsillectomy: An

update
Anand Bangera
Author information ► Copyright and License information ►
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Abstract
Adenotonsillectomy remains one of the most common surgical procedures carried
out in children. Though a commonly performed procedure, it poses a great
challenge to the surgeon as well as the anaesthesiologist and is associated with a
substantially increased risk of morbidity and mortality. In the post-operative
period, it poses threats such as post-tonsillectomy bleeding and airway obstruction
if not diagnosed and treated promptly. Various recent advances in airway
management and early detection of post-operative complications have been made
to reduce the sequelae associated with tonsillectomy. In this article, we have
reviewed the various techniques, complications and recent advances, which have
evolved in the anaesthetic technique related to adenotonsillectomy.

Keywords: Anaesthesia, bleeding tonsil, recent advances, laryngospasm

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INTRODUCTION
Tonsillectomy with or without adenoidectomy is a long practiced and one of the
most frequently performed surgical procedures in paediatric age group worldwide.
The number has declined by approximately 50% from about 1.4 million in 1959 to
about 2 lakh per year till date.[1] Though a commonly performed procedure, it
poses a great challenge to the surgeon as well as the anaesthesiologist and is
associated with a substantially increased risk of morbidity and mortality.[1,2]

In this article, we have reviewed the available information about the techniques,
complications and recent advances. We reviewed studies, research articles,
guidelines and meta-analysis from PubMed, Google Scholar, etc., using the
following key words: adenotonsillectomy, posttonsillectomy bleeding and recent
advances.

The tonsils and adenoids are lymphoid tissues forming part of the Waldeyer's ring
encircling the pharynx. It appears in the 2nd year of life and attains the largest size
between 4 and 7 years of age and then regresses.[1,2]

Clinical features of adenotonsillar hypertrophy are nasal obstruction, recurrent

infections, secretory otitis media, decreased hearing (secondary to Eustachian tube
dysfunction) and obstructive sleep apnoea (OSA).[1]

As per the American Academy of Otolaryngology–Head and Neck Surgery, the

absolute indications of the procedure are enlarged tonsils with features of upper
airway obstruction, dysphagia, sleep disorders, peritonsillar abscess not adequately
responding to medical management, febrile seizures due to tonsillitis and tonsillar
pathology requiring biopsy for a definitive diagnosis.[3]

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DEMOGRAPHY AND HISTORY

The surgical rates are age and gender specific. Tonsillectomy is usually performed
in older children whereas adenoidectomy is indicated in younger age group.
Adenoidectomy has more of a male preponderance and tonsillectomy has more of
female preponderance for unknown reason.[4]

This procedure was first described in the Hindu literature in 1000 BC. Cornelius
Celsus and Paul of Aegina invented the blunt removal using their own fingernail or
a metal hook. Samuel J. Crowe popularised the use of Crowe–Davis mouth gag
and sharp dissection. In the early 20th century, complete tonsillectomies came into
clinical practice and have evolved to the modern day.[5]

For a long time, the tonsillectomy operations were performed without anaesthesia,
and general anaesthesia for adenotonsillectomies came into vogue around 1935.
Two of the popular methods were the single dose method with ethyl chloride or
nitrous oxide and ether insufflations of the oropharynx. Anaesthesia for
tonsillectomies has evolved greatly to the present day with operations being
performed under local as well as general anaesthesia. Airway management gained
importance using endotracheal tube (ETT) or laryngeal mask airway (LMA) with
either spontaneous or controlled ventilation, each technique having their own pros
and cons. Post-operative pain and the incidence of nausea and vomiting have been
greatly reduced with improved techniques and the use of multimodal
approaches.[6,7]

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GOALS OF ANAESTHETIC MANAGEMENT

Anaesthesia for adenotonsillectomy is a challenge to the anaesthesiologist. A safe
conduct of anaesthesia is of utmost importance to avoid the complications and
associated anxiety of the patient as well as the parents. Good communication
between the surgeon, anaesthesiologist and the parents of the child is a must for a
successful outcome.

The goals are adequate patient preparation with premedication, providing good
surgical access while 'sharing the airway', optimising perioperative analgesia,
preventing post-operative nausea and vomiting (PONV), perioperative airway
management and prevention and timely management of post-operative
haemorrhage and other complications.

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SPECIAL CONCERNS
The concerns during the pre-operative evaluation of a patient presenting for
adenotonsillectomy are those associated with the patient's age (paediatric age
group), the American Society of Anesthesiologists physical status, recurrent upper
respiratory infection (URI) episodes, associated comorbidities and coexisting
syndromes. A special emphasis must be given on the history of bleeding tendencies
and easy bruising, if any.[1,2] The risk for untoward respiratory complications
following surgery include young age, medical comorbidity, OSA syndrome and
recurrent respiratory infections.[1] Historically, the chief indication for
adenotonsillectomy was recurrent infection. However, an increasing number of
children are now presenting with obstructive symptoms as well as OSA syndrome
(OSAS).[7,8]

Obstructive sleep apnoea syndrome and adenotonsillectomy

Children present with a far more different symptomatology as compared with
adults. Daytime drowsiness and obesity are commonly seen in adults. Children
present with an inability to thrive, issues with behaviour and poor school
performance.[9,10,11] Severity of disease does not coincide with the
symptomatology. Polysomnography, which is more specific, is not always
available in all centres. The simpler and cheaper overnight oximetry provides
evidence of severity of OSAS.[12] Surgery is the answer for patients with clinical
features and symptoms suggesting OSAS. The anaesthesiologist must keep in mind
of the increased post-operative complications expected in this high-risk group.

Upper respiratory infection

The question which arises in the presence of URI is whether to proceed with
surgery and anaesthesia or to delay? URI in children is quite common, and most
children experience 6–8 episodes per year. Airway reactivity is a persistent
problem in this group of patients even after several weeks. It is suggested to
proceed with anaesthesia and surgery if the infection is mild. These patients are at
an increased risk of post-operative respiratory problems. High-risk patients include
prematurity, age <5 years, use of an ETT, reactive airway disease, paternal
smoking, copious secretions, nasal congestion and a high total white blood cell
(WBC) count.[11] Whenever patient has fever with high total WBC count, thick
mucopurulent secretion and associated lower respiratory tract infection, it is better
to postpone the surgery for a later date.

The choice of anaesthetic technique matters, especially in the presence of URI.

Evidence suggests that LMA may have advantages over tracheal tube, but it has
not been used frequently for adenotonsillectomy. Anaesthetic medications with
lower potency of airway irritation such as propofol, sevoflurane and halothane are
preferred over those which cause airway irritation such as thiopental and
desflurane. There is no definitive data on the use of anticholinergic drugs to reduce
airway reactivity in a patient with URI. It has been suggested for deep extubation
in a child with URI, but evidence is lacking as to which method has superiority
over the other in patients with URI.[13,14,15]

Pre-operative investigations required are haemoglobin and haematocrit to rule out

anaemia and polycythemia (in patients with OSA), total and differential WBC
count to rule out active chest infection, bleeding and clotting time, prothrombin
time and International Normalised Ratio (these tests are more relevant compared to
bleeding time clotting time) and electrocardiogram (ECG) in patients with OSA (to
rule out right heart involvement secondary to pulmonary artery hypertension). Pre-
operative room air saturation will be of great help in selected cases.

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PRE-OPERATIVE ANXIETY
The factors to be taken into consideration during this procedure are the younger
age of the patient, anxiety of parents and associated behavioural problems, which
increases the pre-operative anxiety. In addition, surgery lasting >30 min and
previous admission to the hospitals are known risk factors for increased
anxiety.[16,17,18] Premedication with oral midazolam (0.5 mg/kg) has been
shown to be safe and reliable, and other drugs such as clonidine may be effective.
Anxiolytics/sedatives must be carefully titrated in patients with OSAS as they are
more prone to airway obstruction. As per data, presence of parents during
induction of anaesthesia is of no proven benefit to reduce patient
anxiety.[19,20,21]

Pedicloryl (triclofos), which is commonly used for younger children, has the
potential to cause airway obstruction, especially in patients with big tonsils.
Intranasal midazolam, fentanyl lollipop and recently drugs such as
dexmedetomidine are used with varying results.

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INTRA-OPERATIVE MANAGEMENT
A meticulous pre-anaesthetic evaluation and patient preparation is the key to
successful anaesthetic management of adenotonsillectomy patients. Proper
preparation of the operating room (OR) including the emergency drugs and airway
equipment (appropriate size-reinforced LMA, Ring, Adair and Elwyn [RAE] and
conventional ETTs, oral airways, working suction apparatus and anaesthesia drugs
as per protocol) should be done. Good intravenous (IV) access is essential, and IV
fluids as per body weight are advocated. Eyes must be taped and protected. Basic
monitors including ECG, non-invasive blood pressure, pulse oximetry, end-tidal
carbon dioxide (EtCO2), precordial stethoscope, temperature probe and
neuromuscular monitoring must be available. EtCO2 is a very important tool to
detect the ET tube obstruction due to the gag pressing on the tube and also the
displacement of the ETT. Specific drugs which can be irritant to the airway (e.g.,
thiopentone, desflurane) and drugs causing significant side effects such as
suxamethonium (dysrhythmias, hyperkalaemia, sudden unexpected death, muscle
pain, malignant hyperthermia, masseter spasm and prolonged neuromuscular
blockade in face of cholinesterase deficiency) must be avoided. However,
suxamethonium has a role in peripheral setup and in patients with suspected
difficult airway. Drugs known to cause histamine release (atracurium) must be
avoided.[13]

Propofol is the most commonly used induction agent. Furthermore, propofol

maintenance decreases the incidence of PONV as compared to isoflurane.
Isoflurane is the most commonly used volatile agent for maintenance followed by
halothane and sevoflurane.[13,14]

The gold standard of airway management during tonsillectomy surgery remains a

tracheal tube. A preformed south pole-facing tube (oral RAE) is preferable, but we
have to ensure that the surgeon uses a Boyle–Davis gag [Figure 1] with a central
slit. Tube placement must be confirmed by bilateral auscultation after patient is put
on position and Boyle–Davis mouth gag placement. Currently, there are an
increasing number of surgeries done using LMA, usually reinforced type. Use of
an LMA requires adequate training and experience for safe conduct of anaesthesia
and has a learning curve associated with it. Anaesthesiologists must be aware of
the possibility of airway obstruction that might occur with the use of Boyle–Davis
mouth gag; the airway pressure must be checked.[1,2,14] After the surgery,
patients must be extubated in lateral and head low position (post-tonsillectomy
position) which should be maintained in the post-operative period.[18]
Achievement of haemostasis and throat free of secretions or any gauze must be
confirmed before extubation. Patients must be shifted to recovery room in lateral
position and must be monitored for bleeding as well as deterioration of
consciousness.[1,14]

Figure 1
Positioning with Boyle – Davis gag with a slit for RAE tube

Coroner's clot

It is an occult clot of blood left behind the nasopharynx posterior to the soft palate.
It usually occurs in surgeries in the area of nasopharynx or trauma,
adenotonsillectomy being one of the common causes. It has the potential to cause
fatal airway obstruction following extubation. In the past, the clot was retrieved
only during the postmortem and hence the name. Management includes careful
suctioning of the throat and nasopharynx under vision of a direct laryngoscope,
especially in high-risk patients. Flexion of the neck during laryngoscopy can be
useful to bring the clot more anterior and facilitate removal by suction.

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POST-OPERATIVE ANALGESIA
Multimodal analgesia is the preferred technique to provide good post-operative
analgesia. A combination of opioids and mild analgesics (non-steroidal anti-
inflammatory drugs [NSAIDs] or paracetamol) as per age-specific indications and
institutional protocol can be administered. Use of local anaesthetic for infiltration
in the tonsillar fossa has found to be particularly effective in alleviating pain.
Adequate post-operative analgesia also reduces the incidence of PONV and
decreases the length of hospital stay.[1,2]

Antiemetics which can be used include ondansetron at a dose of 0.1 mg/kg IV or

dexamethasone at a dose of 0.15 mg/kg IV. Post-operative complications include
pain and throat discomfort, restlessness, nausea and vomiting, bleeding,
laryngospasm and acute pulmonary oedema. The incidence of post-operative
complications is linked to the surgical technique used. Cold steel dissection has the
lowest risk of post-operative haemorrhage.[22] The use of diathermy increases the
risk of post-operative haemorrhage. Extensive use of diathermy is associated with
an increased incidence of post-operative pain.[22,23]

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SPECIAL EMPHASIS
Post-tonsillectomy bleeding

Bleeding tonsil is one of the dreaded complications in this group of patients. It is

an emergency and can lead to rapid deterioration of haemodynamics if not
intervened in time. Three types of haemorrhage have been defined which are
primary bleeding occurring at the time of surgery, secondary bleeding occurring
between 4–6 days and reactionary occurring 8–48 h postoperatively.[24]
The anaesthetic management should be apt and poses many hazards and
challenges. which require proper preparation for airway management, preventing
aspiration and blood volume resuscitation.

The main factors to be considered are a dehydrated, agitated, hypovolaemic child

with stomach full of blood clots, in a child who has just come out of anaesthesia
and muscle relaxation. Signs include increased swallowing, pallor and an
unexplained tachycardia. Investigation must include a full blood count, bleeding
and clotting time, blood grouping and cross-match. Resuscitation must begin even
prior to the commencement of anaesthesia and must be carried out throughout
perioperative period depending on the circumstances.[2]

In a child with bleeding tonsil, large bore IV access with two wide bore cannulae
and working suction should be ready in the OR. The presence of an experienced
anaesthesiologist and a good communication between the surgeon and the
anaesthesiologist helps to tackle this life-threatening emergency. Rapid sequence
induction technique should be followed with dedication.

Laryngospasm

Tonsillectomy and adenoidectomy have the highest incidence of laryngospasm

(21%–26%) in the immediate post-operative period.[25] Laryngospasm can be
self-limiting, but if not treated timely can have deleterious effect and life-
threatening consequences. Negative pressure pulmonary oedema, pulmonary
aspiration, bradycardia, oxygen desaturation and cardiac arrest are known
complications of laryngospasm. Patients must be given 100% oxygen and help
should be sought for. Agents which are known to decrease the incidence of
laryngospasm are topical lignocaine spray (up to 4 mg/kg) or IV 2% preservative-
free lignocaine (1.5 mg/kg) 3 min before extubation. Magnesium sulphate 15
mg/kg over 20 min after tracheal intubation has shown to reduce the incidence of
post-adenotonsillectomy laryngospasm. Use of IV propofol 0.25–0.5 mg/kg has
also been shown to have positive results.[25] If laryngospasm has occurred, the
Larson's manoeuvre can be used to break the spasm. Refractory cases can be
managed with succinylcholine 0.5–0.8 mg/kg IV.

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USEFUL PRACTICES AND CONTROVERSIES

Day care adenotonsillectomy
Nowadays, more and more adenotonsillectomies are being performed on day care
basis. This involves good communication between the surgeon, anaesthesiologist
and the parents of the child. A proper review of the procedure and the probable
problems which may occur must be explained to the parents. Patients suitable for
day care surgery in this group are the ones with uncomplicated medical history,
who have easy transport available and who can be in hospital within an hour in
case of emergencies. An Operational Guide Department of Health in 2002 included
adenotonsillectomy in the list of day care procedures.[26] A careful patient
selection is the key to improve the scope of day care adenotonsillectomies. Patients
unfavourable for day care procedure include age <3 years, significant comorbidity,
OSA, living >1 h drive from the hospital or having no private transport. A major
problem to be dealt with is that of primary and reactionary haemorrhage and
PONV. An extended observation period of 4–6 h before discharge is usually
recommended. There is an increased incidence of overnight admission with
PONV, pain and poor oral intake.[1,17,18] A multimodal plan of analgesia and
proper antiemetics perioperatively reduces these problems. In Indian scenario,
because of the not uncommon post-operative complications such as bleeding and
airway obstruction, adenotonsillectomy is rarely practiced as a day care procedure.

Spontaneous or controlled ventilation

Studies suggest that there is no difference between the intra- and post-operative
complications apart from an increase in EtCO2 with spontaneous ventilation. IPPV
results in less haemodynamic variations and better recovery characteristics. The
incidence of PONV and agitation is slightly increased during spontaneous
ventilation as compared with controlled ventilation.[15,27] Thus, spontaneous
ventilation has to be discouraged in the present-day practice.

Local infiltration anaesthesia

Lesser palatine and glossopharyngeal nerve blocks combined with general

anaesthesia improves the operative conditions and provides excellent post-
operative analgesia. Adult patients report pain-free periods almost up to 6 h
postoperatively. The extubation process is much smoother in children receiving
local anaesthesia in conjunction with general anaesthesia.[7,15]

Use of non-steroidal anti-inflammatory drugs

There is ongoing controversy regarding the use of NSAIDS in post-tonsillectomy

patients with regard to its antiplatelet aggregating property. Till date, there are
insufficient data to conclude that NSAIDS are associated with an increased
incidence of bleeding with tonsillectomy. However, the use of ketorolac has been
found to have increased incidence of bleeding as evidenced in a Cochrane analysis
and hence must be avoided.[1,2] Thus, paracetamol suppository is quite popular
for post-operative analgesia.

Extubation - deep versus awake

There is existing controversy regarding deep versus awake extubation. At present,

there are no studies which clearly state one study to be better over the other. Deep
extubation in these patients with head down left lateral position is preferred by
some in spite of blood or secretions in the pharynx during tonsillectomy
anaesthesia. The quality of recovery is smooth and undisturbed with reduced
chances of oozing from the operative site. Studies have shown no difference in
complication rate whether extubated deep or awake.[15,28] Use of IV lignocaine
before extubation and intraoperative use of recent drugs such as dexmedetomidine
and safer long-acting antiemetic drugs make the post-extubation and recovery
period pleasant and uneventful.

Superhydration to prevent nausea and vomiting

PONV is a frequent complication in children that leads to prolonged stay and

increased rates of readmission. Various studies have compared the effect of
intraoperative hydration with 10–30 ml/kg/h of Ringer's lactate on PONV in
children aged 1–12 years undergoing tonsillectomy. The higher volume hydration
protocol significantly reduced PONV, and is cost-effective in the absence of
prophylactic antiemetic therapy.[25,29] To avoid the risk of volume overload
leading on to pulmonary oedema, this technique should be restricted only to older
children.

Laryngeal mask airway versus tracheal tube

The tracheal tube provides a definitive airway, and a 'south-facing' oral RAE
[Figure 2] tube positioned in the midline provides good surgical access. The
disadvantages with tracheal intubation include the need for muscle paralysis, a
deeper plane of anaesthesia, possibility of endobronchial intubation or accidental
extubation with hyperextension of the neck. It is considered as gold standard as it
provides a definite protection against aspiration. The question of deep or awake
extubation to avoid a stormy emergence and bleeding also exists. The reinforced
LMA offers a good airway, avoids the use of neuromuscular blocking agents,
allows smooth emergence and airway protection until fully awake. The LMA can
be removed with the cuff which is still partially inflated to avoid seeping of oral
contents into the trachea. Hence, considering these advantages, the use of
supraglottic airway devices such as LMAs should be encouraged.

Figure 2
Ring Adair Elwyn tubes (south pole facing and north pole facing)

An incorrectly sized LMA or too large blade on the mouth gag can lead to
obstruction and must be carefully checked.[1,2,15] LMA does not offer the
definitive airway and it may restrict surgical access in younger patients. Airway
patency must be re-confirmed before surgery proceeds with the use of both LMA
and tracheal tube.

Nasal or oral intubation

In olden days, surgeons used to prefer nasal intubation as it provides wider surgical
field, but it was associated with various disadvantages such as epistaxis, adenoid
injury, nasopharyngeal tear and infection. Nowadays, with oral RAE tube, one can
remove the elbow connector and anaesthetic breathing circuit from the surgical
field with less trauma and infection rates. However, the oral RAE is associated
with accidental bronchial intubation, cuff placement between the cords or
displacement of tube.

Dexmedetomidine for the prevention of emergence agitation

Dexmedetomidine at the dose of 0.25–0.38 μg/kg has been tried to provide stable
intraoperative haemodynamics and also to prevent emergence agitation produced
by sevoflurane and desflurane. Thus, dexmedetomidine may have a definitive role
in the prevention of emergence agitation after tonsillectomy.[30]

Adenotonsillectomy in rural settings

There is still a lingering controversy on the fate of day care adenoidectomy in rural
settings. There is mixed evidence on including it as a day care procedure in rural
settings given the lack of infrastructure and facilities in rural places. There are
studies which show an increasing trend of day care adenotonsillectomies
performed in the rural settings, provided the patient selection is appropriate.[31]
Anaesthesiologists must be aware that there are higher chances of morbidity
associated with this procedure, especially in the rural settings with lack of
infrastructure, adequate equipment and support staff.

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SUMMARY
Adenotonsillectomy, is still associated with life-threatening complications such as
post-operative bleeding and airway obstruction. Hence, it should be dealt with
utmost care, especially in peripheral setups with limited facilities as majority of
these patients are of the paediatric age group coming from rural areas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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